ADAM SMITH ON MEDICAL EDUCATION AND RELATED MATTERS

(From the Institute for Biological Research, Johns Hopkins University. Reprinted from the Journal of the American Medical Association 85 [1925]: 1663-65)

RAYMOND PEARL, Ph.D., D.Sc., LL.D.

During the last year there has been much discussion of the economics of medical education and of medical practice.1Many physicians in rural locations have difficulty in making income and outgo maintain a satisfactory relation to each other. It has been suggested that this unfortunate state of affairs arises because medical education has become too expensive, as a result primarily of an ever widening and deepening curriculum. Another suggestion is that the physician, whether urban or rural, merely finds himself enmeshed in the general social and economic circumstances of the times, along with lawyers, preachers, farmers and others, and that his economic difficulties are not peculiarly consequent on either this profession or his education. Whether either or neither of these suggestions is true is not easy of determination, because of the complexity and variety of the factors involved in the problem.

In the meantime, it occurs to me that it will be of interest to read what Adam Smith, the great economist, had to say regarding these matters just a century and a half ago. Probably to no great number of medical men in America are the contents of the letter, which is here reprinted, known; indeed, many do not even know of its existence. But any one who reads it now will be forcibly struck once more with another instance of that common observation that few of the problems of human life have, even in details, any particular novelty. While it is not of record that Mousterian man, sitting in his caverns in that paleolithic metropolis now called Les Eyzies, ever discussed the economics of medical education, I incline somewhat to the opinion that it is only the paucity of any records of these days that enables one to say this.

The circumstances leading to the writing of this letter by Adam Smith were these: For a long time prior to the latter part of the eighteenth century it had been the practice of the universities of St. Andrews and Aberdeen to grant the medical degree in absentia to any person who was able to persuade, by any means whatever, any two physicians to certify that they regarded him as worthy of an M.D. Obviously, this was not a difficult requirement to satisfy, and some very rare birds indeed took advantage of this short, cheap and easy route to the doctorate. So much so that, in 1773, the matter became openly scandalous and the great William Cullen, of nosological fame, at that time professor of the institutes of medicine at Edinburgh, decided to do something about the matter. Accordingly, in 1774, he memorialized Henry, the third Duke of Buccleuch, to enlist his influence to get a Visitation of the Scotch universities "with a view to the correcting of these and other abuses in their constitution and discipline." The duke refused to move in the matter until the memorial had been submitted to his old tutor and friend Adam Smith and his opinion on it had been obtained. Cullen presented his case, and his views thereon, to Smith, and got, in due time, the reply here reprinted. This letter, which amounts to a treatise on medical education and practice, was written two years before the publication of "The Wealth of Nations." It is reprinted as one of the appendixes to McCulloch's edition of that great book. It is also to be found in Thomson's "Account of the Life, Lectures, and Writings of William Cullen, M.D."2Both Thomson and McCulloch spend some pages in discussing the letter, but their views are of no particular present interest.

“My dear Doctor:

“I have been very much in the wrong both to you and to the Duke of Buccleugh, to whom I certainly promised to write you in a post or two, for having delayed so long to fulfil my promise. The truth is, some occurrences which interested me a good deal, and which happened here immediately after the duke's departure, made me forget altogether a business which I do acknowledge interested me very little.

“In the present state of the Scotch Universities; I do most sincerely look upon them as, in spite of all their faults, without exception the best seminaries of learning that are to be found anywhere in Europe. They are, perhaps, upon the whole, as unexceptionable as any public institutions of that kind, which all contain in their very nature the seeds and causes of negligence and corruption, have ever been, or are ever likely to be. That, however, they are still capable of amendment, and even of considerable amendment, I know very well, and a Visitation is, I believe, the only proper means of procuring them this amendment. Before any wise man, however, would apply for the appointment of so arbitrary a tribunal, in order to improve what is already, upon the whole, very well, he ought certainly to know with some degree of certainty first, who are likely to be appointed visitors; and, secondly, what plan of reformation those visitors are likely to follow. But, in the present multiplicity of pretenders to some share in the provincial management of Scotch affairs, these are two points, which I apprehend neither you nor I, nor the Solicitor-General, nor the Duke of Buccleugh. can possibly know anything about. In the present state of our affairs, therefore, to apply for a Visitation in order to remedy an abuse, which is not perhaps of great consequence to the public, would appear to me to be extremely unwise. Hereafter, perhaps an opportunity may present itself for making such an application with more safety.

“With regard to any admonition or threatening, or any other method of interfering in the affairs of a body corporate, which is not perfectly and strictly regular and legal, these are expedients which I am convinced neither his Majesty nor any of his present Ministers would choose to employ either now or at any time hereafter, in order to obtain an object even of much greater consequence than this reformation of Scotch degrees.

“The monopoly of medical education which this regulation would establish in favour of Universities would, I apprehend, be hurtful to the lasting prosperity of such bodies-corporate. Monopolists very seldom make good work, and a lecture which a certain number of students must attend, whether they profit by it or no, is certainly not very likely to be a good one. I have thought a great deal upon this subject, and have inquired very carefully into the constitution and history of several of the principal Universities of Europe. I have satisfied myself, that the present state of degradation and contempt into which the greater part of those societies have fallen in almost every part of Europe, arises principally, first, from the large salaries which in some Universities are given to professors, and which render them altogether independent of their diligence and success in their professions; and, secondly, from the great number of students, who, in order to get degrees, or to be admitted to exercise certain professions, or who, for the sake of bursaries, exhibitions, scholarships, fellowships, etc., are obliged to resort to certain societies of this kind, whether the instructions which they are likely to receive there are or are not worth receiving. All those different causes of negligence and corruption, no doubt take place in some degree in all our Scotch Universities. In the best of them, however, those causes take place in a much less degree than in the greater part of other considerable societies of the same kind; and I look upon this circumstance as the real cause of their present excellence. In the medical College of Edinburgh in particular, the salaries of the Professors are insignificant. There are few or no bursaries or exhibitions, and their monopoly of degrees is broken in upon by all other Universities, foreign and domestic. I require no other explication of its present acknowledged superiority over every other society of the same kind in Europe.

“To sign a certificate in favour of any man whom we know little or nothing about, is most certainly a practice which cannot be strictly vindicated. It is a practice, however, which, from mere good nature, and without interest of any kind, the most scrupulous men in the world are sometimes guilty of. I certainly do not mean to defend it. Bating the unhandsomeness of the practice, however, I would ask in what manner does the public suffer by it? The title of Doctor, such as it is, you will say, gives some credit and authority to the man upon whom it is bestowed; it extends his practice, and consequently his field for doing mischief; it is not improbable, too, that it may increase his presumption, and consequently his disposition to do mischief. That a degree injudiciously conferred may sometimes have some little effect of this kind, it would surely be absurd to deny: but that this effect should be very considerable, I cannot bring myself to believe. That Doctors are sometimes fools as well as other people, is not, in the present time, one of those profound secrets which is known only to the learned. The title is not so very imposing, and it very seldom happens that a man trusts his health to another merely because that other is a doctor. The person so trusted has almost always either some knowledge or some craft which would procure him nearly the same trust, though he was not decorated with any such title. In fact, the persons who apply for degrees in the irregular manner complained of, are, the greater part of them, surgeons or apothecaries, who are in the custom of advising and prescribing, that is of practising as physicians; but who, being only surgeons and apothecaries, are not fee-ed as physicians. It is not so much to extend their practice as to increase their fees, that they are desirous of being made doctors. Degrees conferred even undeservedly upon such persons can surely do very little harm to the public. When the University of St. Andrew's, very rashly and imprudently, conferred a degree upon Green, who happened to be a stage-doctor, they no doubt brought much ridicule and discredit upon themselves; but in what respect did they hurt the public? Green still continued to be what he was before, a stage-doctor, and probably never poisoned a single man more than he would have done though the honours of graduation had never been conferred upon him. Stage-doctors, I must observe, do not much excite the indignation of the faculty; more reputable quacks do. The former are too contemptible to be considered as rivals: They only poison the poor people; and the copper-pence which are thrown up to them in handkerchiefs, could never find their way into the pocket of a regular physician. It is otherwise with the latter: They sometimes intercept a part of what perhaps would have been better bestowed in another place. Do not all the old women in the country practice physic without exciting murmur or complaint? And if here and there a graduated doctor should be, as ignorant as an old woman, where can be the great harm? The beardless old woman, indeed, takes no fees; the bearded one does, and it is this circumstance, I strongly suspect, which exasperates his brethren so much against him.

“There never was, and, I will venture to say, there never will be, a University from which a degree could give any tolerable security, that the person upon whom it had been conferred, was fit to practise physic. The strictest Universities confer degrees only upon students of a certain standing. Their real motive for requiring this standing is, that the student may spend more money among them, and that they may make more profit by him. When he has attained this standing, therefore, though he still undergoes what they call an examination, it scarce ever happens that he is refused his degree. Your examination at Edinburgh, I have all reason to believe, is as serious, and perhaps more so than that of any other University in Europe. But when a student has resided a few years among you, has behaved dutifully to all his Professors, and has attended regularly all their lectures, when he comes to his examination, I suspect you are disposed to be as good-natured as other people. Several of your graduates, upon applying for a licence to the College of Physicians here, have had it recommended to them to continue their studies. From a particular knowledge of some of the cases, I am satisfied that the decision of the College, in refusing them their licence, was perfectly just; that is, was perfectly agreeable to the principles which ought to regulate all such decisions, and that the candidates were really very ignorant of their profession.

“A degree can pretend to give security for nothing but the science of the graduate; and even for that it can give but a very slender security. For his good sense and discretion, qualities not discoverable by an academical examination, it can give no security at all. But without these, the presumption which commonly attends science must render it, in the practice of physic, ten times more dangerous than the grossest ignorance, when accompanied, as it sometime is, with some degree of modesty and diffidence.

“If a degree, in short, always has been, in spite of all the regulations which can be made, always must be, a mere piece of quackery, it is certainly for the advantage of the public that it should be understood to be so. It is in a particular manner for the advantage of the Universities, that, for the resort of students, they should be obliged to depend, not upon their privileges, but upon their merit,—upon their abilities to teach, and their diligence in teaching; and that they should not have it in their power to use any of those quackish arts which have disgraced and degraded the half of them.

“A degree which can be conferred only upon students of a certain standing is a statute of apprenticeship which is likely to contribute to the advancement of science, just as other statutes of apprenticeship have contributed to that of arts and manufactures. Those statutes of apprenticeship, assisted by other corporation laws, have banished arts and manufactures from the greater part of towns-corporate. Such degrees, assisted by some other regulations of a similar tendency, have banished almost all useful and solid education from the greater part of Universities. Bad work and high price have been the effects of the monopoly introduced by the former. Quackery, imposture and exorbitant fees, have been the consequences of that established by the latter. The industry of manufacturing villages has remedied in part the inconveniences which the monopolies established by towns-corporate had occasioned. The private interest of some poor Professors of Physic in some poor Universities, inconveniently situated for the resort of students, has in part remedied the inconveniences which would certainly have resulted from that sort of monopoly which the great and rich Universities had attempted to establish. The great and rich Universities seldom graduated anybody but their own students, and not even them till after a long and tedious standing; five and seven years for a Master of Arts; eleven and sixteen for a Doctor of Law, Physic, or Divinity. The poor Universities, on account of the inconveniency of their situation, not being able to get many students, endeavored to turn the penny in the only way in which they could turn it, and sold their Degrees to whoever would buy them, generally without requiring any residence or standing, and frequently without subjecting the candidate even to a decent examination. The less trouble they gave the more money they got, and I certainly do not to pretend to vindicate so dirty a practice. All Universities being ecclesiastical establishments, under the immediate protection of the Pope, a degree from any one of them gave, all over Christendom, very nearly the same privileges which a degree from any other could have given; and the respect which is at this day paid to foreign degrees, even in the Protestant countries, must be considered as a remnant of popery. The facility of obtaining degrees, particularly in physic, from those poor Universities, had two effects, both extremely advantageous to the public, but extremely disagreeable to the graduates of other Universities, whose degrees had cost them much time and expense. First, It multiplied very much the number of doctors, and thereby no doubt sunk their fees, or at least hindered them from rising so very high as they otherwise would have done. Had the Universities of Oxford and Cambridge been able to maintain themselves in the exclusive privilege of graduating all the doctors who could practice in England, the price of feeling a pulse might by this time have risen from two and three guineas, the price which it has now happily arrived at, to double or triple that sum; and English physicians might, and probably would, have been at the same time the most ignorant and quackish in the world. Secondly, It reduced a good deal the rank and dignity of a doctor. But if the physician was a man of sense and science, it would not surely prevent his being respected and employed as a man of sense and science. If he was neither the one nor the other, indeed, his doctorship would no doubt avail him the less. But ought it in this case to avail him at all? Had the hopeful project of the rich and great Universities succeeded, there would have been no occasion for sense or science. To have been a doctor would alone have been sufficient to give any man rank, dignity and fortune enough. That in every profession the fortune of every individual should depend as much as possible upon his merit, and as little as possible upon his privilege, is certainly for the interest of the public. It is even for the interest of every particular profession, which can never so effectually support the general merit and real honour of the greater part of those who exercise it, as by resting upon such liberal principles. Those principles are even most effectual for procuring them all the employment which the country can afford. The great success of quacks in England has been altogether owing to the real quackery of the regular physicians. Our regular physicians in Scotland have little quackery, and no quack accordingly has ever made his fortune among us.

“After all, this trade in degrees I acknowledge to be a most disgraceful trade to those who exercise it; and I am extremely sorry that it should be exercised by such respectable bodies as any of our Scotch Universities. But as it serves as a corrective to what would otherwise soon grow up to be an intolerable nuisance, the exclusive and corporation spirit of all thriving professions and of all great Universities, I deny that it is hurtful to the public.

“What the physicians of Edinburgh at present feel as a hardship is, perhaps, the real cause of their acknowledged superiority over the greater part of other physicians. The Royal College of Physicians there, you say, are obliged by their charter to grant a licence, without examination, to all the graduates of Scotch universities. You are all obliged, I suppose, in consequence of this, to consult sometimes with very unworthy brethren. You are all made to feel that you must rest no part of your dignity upon your degree, distinction which you share with the men in the world, perhaps, whom you despise the most, but that you must found the whole of it upon your merit. Not being able to derive much consequence from the character of Doctor, you are obliged, perhaps, to attend more to your characters as men, as gentlemen, and as men of letters. The unworthiness of some of your brethren, may, perhaps, in this manner be in part the cause of the very eminent and superior worth of many of the rest. The very abuse which you complain of may in this manner, perhaps, be the real source of your present excellence. You are at present well, wonderfully well, and when you are so, be assured there is always some danger in attempting to he better.

“Adieu, my dear Doctor; after having delayed so long to write to you, I am afraid I shall get my lug (ear) in my lufe (hand), as we say, for what I have written. But I ever am most affectionately yours,

ADAM SMITH.

“London, 20th Sept. 1774.”

It would certainly be unwise to risk damage to such a gem by attempting to polish or recut it. I therefore confine myself merely to the completion of the story. Adam Smith's letter stopped all further proceedings. No Visitation was had, and many years passed before the conditions which worried Dr. Cullen, and so little disturbed Adam Smith, were altered by the universities themselves. That the letter had such a result was presumably at that time, as it will be now, deplored by all right-thinking, forward-looking citizens.